ASKING THE 'SPECIAL QUESTIONS'

Asking 'special questions' is a component of every patient examination and generally include the following areas of questioning for symptoms related to the patient problem/history (Van Tulder et al., 2006, p. S172):

Age of onset of pain less than 20 years or more than 55 years.

Recent history of violent trauma.

Questioning of dizziness (5D's & 3N's).

Constant progressive, non mechanical pain (no relief with bed rest).

Thoracic pain.

Past medical history of malignant tumour.

Prolonged use of corticosteroids as well as other long term medications.

Drug abuse, immunosuppression, HIV.

Systemically unwell.

Unexplained weight loss.

Widespread neurological symptoms (including cauda equina syndrome).

Structural deformity.

Fever and night sweats.

General Health – “do you have any other medical conditions?” “how is your general health?”

Investigations – “have you had or been referred for any scans?”

Bladder and bowel disturbance.

Cauda equina sings or signs of cord compression.

... but have you ever found yourself wondering why we are asking them, how to interpret the responses given by our patients, and how to continue questioning deeper when we need to clarify the information gained?

I have written this blog to recap some key information regarding red flags.

Here are some fun statistics (Van Tulder et al., 2006, p. S172)...

The lifetime prevalence of low back pain is reported as over 70% in industrialised countries.

In over 85% of those suffering from lower back pain, the pain is not attributable to pathology or neurological encroachment.

About 4% of people seen with low back pain in primary care have compression fractures and about 1% has a neoplasm.

Ankylosing spondylitis and spinal infections are even more rare.

The prevalence of prolapsed intervertebral disc is about 1% to 3%.

With regards to lower back pain, 97% of cases can be diagnosed as mechanical lower back pain, 2% visceral pain, and <1% from other non-mechanical causes (Jarvik & Deyo, 2012).

It is our professional responsibility to be able to identify those who required further medical examination or treatment. Identifying these patients begins during the subjective examination when we question for the presence of RED FLAGS.

"‘Red flags’ are risk factors detected in patients’ past medical history and symptomatology and are associated with a higher risk of serious disorders causing pain compared to patients without these characteristics. If any of these are present, further investigation (according to the suspected underlying pathology) may be required to exclude a serious underlying condition, e.g. infection, inflammatory rheumatic disease or cancer" (Van Tulder et al., 2006, p. S172).

So what are we trying to look for?...

Presence of signs/symptoms of serious pathology

Constant pain

Pain that is not related to movement

Presence of severe spasm

Morning stiffness >half hour

Presence of severe night pain

Present of night sweats

History of cancer

Recent fracture or trauma

Presence of symptoms of spinal cord compromise

Non-dermatomal symptoms

Ataxia or clumsiness

Increased reflexes

Positive Babinski sign or clonus

Non-myotomal muscle weakness

Presence of symptoms of the following conditions

Active infection

Active Scheuermann's disease

Osteoporosis or osteopenia

Pregnancy

Advanced diabetes

Inflammatory disease

These conditions may have precautions or contraindications to manipulation

Signs of possible spinal instability in

Rheumatoid Arthritis

Spondylolisthesis

Symptoms of acute spinal nerve or nerve root compression

Dermatomal pain or paraesthesia or anaesthesia

Decreased reflexes

Decreased myotomal power

Production of neurological signs with spinal movements

Use of medication

Anti-depressants

Anti-coagulants

Oral Steroids

Strong analgesia

Muscle relaxants

Opiates

DIFFERENTIAL DIAGNOSIS FOR EACH AREA OF THE SPINE

Cervical spine

Disorders that may stimulate spinal pain in the cervical spine include (Maitland, 2005):

Malignant lymphadenopathy.

Pancoast's tumour.

Vertebral artery syndrome.

Subarachnoid haemorrhage.

Coronary artery disease.

Polymyalgia rheumatica.

Thoracic Spine

Disorders that may stimulate spinal pain in the thoracic spine include (Maitland, 2005):

Bronchogenic carcinoma.

Other lung disease.

Coronary artery disease.

Aortic aneurysm.

Massive cardiac enlargement.

Hiatus hernia.

Gall bladder disease - cholecystitis.

Herpes zoster.

Lumbar spine

Disorders that may stimulate spinal pain in the lumbar spine include (Maitland, 2005):

Peptic ulcer.

Renal disease.

Pancreatic carcinoma.

Obstruction of aorta or iliac arteries.

Carcinoma of colon or rectum.

Other pelvic carcinomas.

Endometriosis.

Pregnancy.

Disseminated sclerosis.

Spinal cord tumour.

Hip disease.

DIZZINESS AND CAUDA EQUINA/CORD COMPRESSION

So just to look a step closer at the signs we are looking for and how to expand our questioning further....

Dizziness is the most common complaint associated with vertebrobasilar insufficiency (VBI). When dizziness is present you must assess for the presentation of the following symptoms (the presence of one of these symptoms is enough to warrant caution and further investigation).

5D's

Dizziness

Diplopia, blurred vision or transient hemianopia

Drop attacks (loss of power or consciousness)

Dysphagia (problems swallowing)

Dysarthria (problems speaking)

3 N's

Nystagmus

Nausea or vomitting

Other neurological symptoms

5 others

Light headiness or fainting

Disorientation or anxiety

Disturbances in the ears - tinnitus

Pallor, tremors, sweating

Fascial paraesthesia or anaesthesia.

Emergency referral is required when a patient presents with cauda equina sings or signs of cord compression i.e

Bladder dysfunction (usually urinary retention),

Faecal incontinence,

Saddle anaesthesia,

Global / progressive upper or lower limb weakness, and

Gait disturbance.

Glove or stocking paraesthesia in the limbs.

Hopefully this blog expands on your current understanding of red flags or reminds you of the depth the questioning can go into when are trying to identify sinister pathology. I always find it helpful to know why I'm asking these questions to my patients and what answers I am hoping/not hoping to receive.